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Based on observation, record review and interview, the hospital failed to ensure compliance with 42 CFR 489.20 in 1 of 6 required areas (C-2402: Sign Posting); and failed to ensure compliance with 42 CFR 489.24, in 3 of 6 required areas (C-2403:Maintain Transfer Records for 5 Years, C-2407: Stabilizing Treatment, and C-2409: Appropriate Transfer). This has the potential to affect all regional area patients that present to this emergency department.

Findings include:

1) The hospital failed to have EMTALA signage in their obstetrics department for obstetrics patients seeking a MSE (Medical Screening Exam). (Reference C-2402)

2) The hospital failed to maintain transfer records for patients for a minimum of 5 years. (Reference C-2403)

3) The hospital failed to ensure that patients leaving AMA (against medical advice) were provided with information of the benefits and risks of examination and/or treatment. (Reference C-2407)

4) The hospital failed to ensure that physician certification documentation of transfer risks was specific to the patient's condition. (Reference C-2409)

Based on observation, record review and interview, the hospital failed to have EMTALA (Emergency Medical Treatment and Labor Act) signage in 1 of 2 emergency medical screening areas (obstetrics department). This has the potential to affect all regional area obstetrics patients that present to this emergency department.

Findings include:

The 4/27/16 record review of hospital policy " Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance, effective 11/10" revealed no documented information about signage posting in the obstetrics department or other areas where a medical screening exam may occur.

Obstetrics department observations on 4/29/16 from 9:55 a.m. through 10:30 a.m. revealed no EMTALA signage at the entrance door or the nursing station registration area.

During interview with obstetrics RN (registered nurse) A on 4/29/16 at 10 a.m., A stated "we directly admit obstetrical patients over 20 weeks to our unit for medical screening exams". A stated "we do not have (EMTALA) signs in any of our patient rooms".

During interview with Patient Care Services Vice President B on 4/29/16 at 10:30 a.m., B stated "We had an EMTALA sign posted across the nursing station on the wall, but we re-painted the walls and the signage was not put back up". B stated "The (EMTALA) signage has been down for about 3 weeks".

Based on record review and interview, the hospital failed to ensure that medical transfer records are maintained for a minimum of 5 years, for 1 of 4 types of hospital patient records maintained (Minor patients). This has the potential to affect all regional area minor (under 21 years of age) patients that present to this emergency department.

Findings include:

The 4/27/16 record review of hospital policy " Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance, effective 11/10" revealed under "I. Emergency medical care logs shall be maintained for five years...". There is no documented information in this policy regarding the maintenance of patient transfer records.

The 4/28/16 record review of hospital policy "Retention of Medical Records, effective date: April 2016" revealed under "Hospital Records: ...
B. Hospital paper records are destroyed if the patient has not been seen in the clinic for 10 years with the following exceptions:
a. Records of minor patients are maintained for 3 years past the years of majority (21 years)." This policy defines that a 20 year old minor patient would have emergency room transfer records maintained for a maximum of 4 years.

During interview with Patient care Services Vice President B on 4/28/16 at 4:30 p.m., B stated and verified that the medical records retention policy covers the emergency department, and stated that "we did not realize that".

Based on record review and interview, the hospital failed to ensure that patients leaving the emergency department AMA (against medical advice) were informed of risks and benefits of examination and/or treatment, in 1 of 20 patients reviewed (Patient #6). This has the potential to affect all regional area patients that present to this emergency department.

Findings include:

The 4/27/16 record review of hospital policy " Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance, effective 11/10" revealed under "L. If a patient waiting for medical screening decides to leave without examination that following steps should be taken if at all possible:
-Explain to the patient it is important to have the medical screening to rule out whether or not they have a medical condition that needs treatment; ...
-Inform the patient of the risks of not having the medical screening;
-Ask the patient to sign the AMA form acknowledging they understand the risks of leaving without the medical screening;
-Document on the medical record the above information and if they refuse to sign the AMA, document that on the record as well."

The 4/29/16 record review of Patient #6's 2/20/16 at 7:28 p.m. emergency department visit for Jaundice revealed that patient left AMA, during the medical screening exam, at 8:57 p.m. There was no documented evidence that this minor patient's representatives were informed in writing or verbally of the risks and benefits of examination and/or treatment before they left.

During the 4/29/16 at 11:07 a.m. interview with Director of Clinic/Quality D, D stated "we have no further information" regarding documentation of medical screen risk /benefits.

During the 4/29/16 at 11:30 a.m. interview with Physician C, who cared for Patient #6 on 2/20/16, C stated that "I did not provide them with information on the risk or benefits of completing the medical screen".

Based on record review and interview, the hospital failed to ensure that transferring patient's certification forms had documented risk information that was specific to the patient's condition, in 2 of 20 patients reviewed (Patient's #18 and #19). This has the potential to affect all regional area patients that present to this emergency department.

Findings include:

The 4/27/16 record review of hospital policy "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance, effective 11/10" revealed no documented information regarding the physician documentation on the transfer certification form.

The 4/28/16 record review of hospital's "Medical Staff Bylaws, approved on 8/11/15 and 8/25/16" and "Medical Staff Rules and Regulations, dated January 2016", under " VI. General Rules Regarding Emergency Services" revealed no documented information regarding the physician documentation on the transfer certification form.


1) The 4/29/16 record review of Patient #18's 10/21/15 at 2:45 a.m. emergency department visit for Hypoplasia of the left ventricle with vomiting and decreased oral intake revealed a 10/21/15 at 3:40 a.m. "authorization of transfer" form written by Physician E. Under "physician certification", Physician E documentation revealed "1. Benefits of transfer: Peds cardiology eval(ulation) / observ(ation)". "2. Risks of transfer: (circle with line through it) specific" (meaning "none specific").

2) The 4/29/16 record review of Patient #19's 10/3/15 at 3:50 p.m. emergency department visit for Spleen Laceration revealed a 10/3/15 at 7 p.m. "authorization of transfer" form written by Physician F. Under "physician certification", Physician E documentation revealed "1. Benefits of transfer: Trauma Injury". "2." Under "Risks of transfer" the area was blank. There is no documented evidence that Physician F certified risks for transfers for Patient #19 or Patient #19's representatives.

During the 4/29/16 at 11:07 a.m. interview with Director of Clinic/Quality D, D stated "we have no further information" regarding certification of risks for Patient #'s 18 and 19.